Randomized trials of alcohol-use interventions with college students and their parents: lessons from the Transitions Project.

BACKGROUND: Matriculation from high school to college is typified by an increase in alcohol use and related harm for many students. Therefore, this transition period is an ideal time for preventive interventions to target alcohol use and related problems. PURPOSE: The purpose of this report is to describe the design and methods used in the Transitions Project, a randomized controlled trial of two interventions designed to prevent and reduce heavy episodic drinking and alcohol-related negative consequences among incoming college students. METHODS: This study used a 2 × 2 factorial design to investigate the effects of a two-session brief motivational intervention delivered to students and a handbook-based parent intervention. Interventions were administered to students and parents. Follow-up assessment took place at 10- and 22-months post-baseline. RESULTS: The Transitions Project successfully recruited and retained participants across a major transition period (i.e., entering college), administered and compared two distinct but complementary interventions, and collected and analyzed highly skewed data. The application of a factorial design and two-part latent growth curve modeling allowed us to examine main and interactive intervention effects in terms of both initiation and growth in heavy drinking and alcohol-related problems. LIMITATIONS: While we conducted successful tests of our primary and secondary study hypotheses over a lengthy follow-up period, our study design did not permit full interpretation of null findings. We suggest that researchers carefully consider assessment timing, tests of assessment reactivity, and ensure objective tests of intervention efficacy when conducting clinical trials of motivational interventions. CONCLUSIONS: The lessons we learned while conducting this trial have the potential to assist other researchers designing and conducting future preventive interventions targeting parents and college students. The data analytic procedures presented can also help guide trials that plan to analyze zero-inflated non-normal outcome data.

Interactive versus noninteractive interventions and dose-response relationships for stage-matched smoking cessation programs in a managed care setting.

This study compared interactive and noninteractive smoking cessation interventions for a population of smokers who were all members of 1 division of a managed care company. In addition, it examined whether a dose-response relationship existed. Screening was completed for 19,236 members who were contacted by telephone or mail. Of the 4,653 who were identified as smokers, 85.3% were enrolled. A 2 Intervention (interactive or noninteractive) x 4 Contacts (1, 2, 3, or 6 contacts) x 4 Occasions (0, 6, 12, and 18 months) design was used. The interactive intervention was stage-matched expert-system reports plus manuals; the noninteractive intervention was stage-matched manuals. Contact occurred in 1 of 4 series (1, 2, 3 or 6 contacts) at 3-month intervals. The expert system outperformed the stage-matched manuals, but there was no clear dose-response relationship for either intervention.

Alcohol consumption, gender and self-reported hypertension.

This study examines the relationship of alcohol consumption and self-reported lifetime prevalence of hypertension among 19,284 non-institutionalized civilians in the United States. Cross-sectional data from the 1983 National Health Interview Survey, a national probability sample, were examined for each sex separately. Women who report hypertension consumed significantly less alcohol than women who did not report hypertension. Self-reported hypertensive men consumed equal or greater amounts of alcohol than self-reported normotensive men. Alcohol consumption was significantly associated with greater risk of hypertension among men, but not among women. After controlling for other risk factors significant effects for hypertension were found among males who on average consumed more than one drink/day. Beer consumption and spirits consumption above three drinks/day were significant predictors of male hypertension after adjustment for the confounding effects of other alcoholic beverage consumption and other risk factors. This study suggests that alcohol consumption by men who know that they are hypertensive is an important public health concern, with policy implications for targeting prevention efforts.

Alcoholic beverage type, recall period effects and functional disability: evidence from the 1983 NHIS.

To replicate a Canada Health Survey (CHS) study that found beer drinking was associated with lower morbidity, National Health Interview Survey (NHIS) data for 19,462 persons were used to examine associations between functional disability and beverage specific ethanol consumption. A functional disability index consisting of morbidity and symptom coping events reported for 2 weeks prior to the NHIS interview was constructed. Alcohol consumption was reported for the same period as disability (coincident recall), or for the 2 weeks prior to the respondent's last drink during the past year (antecedent recall). The analysis controlled for confounders using direct standardization and multiple logistic regression. The results of this investigation were not consistent with the CHS study. Former drinkers and antecedent recall drinkers reported greater disability rates than either non-drinkers or coincident recall drinkers. Antecedent recall drinkers exhibiting a preference for beer and wine were, respectively, 40 and 80 percent more likely to be disabled than non-drinkers. Further, this study found no evidence of a protective effect among any subgroup of drinkers. The finding of a significant interaction between alcohol consumption and alcohol recall period suggests that epidemiologic studies should give greater attention to the classification of drinker groups by proximity of alcohol consumption.

Task difficulty determines the differential memory-impairing effects of EAA antagonists in gerbils.

Excitatory amino acid antagonists (EAAAs) have been shown to disrupt learning and memory in a variety of cognitive tasks. EAAAs have been reported to produce differential effects on working memory (WM) and reference memory (RM) or to have no effect at all. Apparent selective effects of EAAAs on WM and/or RM may have been due to differences between the effects of competitive and noncompetitive EAAAs, dose selection, or to different task requirements for the WM and RM components. In the present experiments, we assessed the effects of a noncompetitive EAAA (MK-801), a competitive EAAA (CPP), and the muscarinic antagonist scopolamine in two cognitive tasks, the split-stem T-maze and the eight-arm radial maze. In these two tasks, the WM and the RM components differed in their relative degree of difficulty. Gerbils were trained on either the T-maze, where WM was more difficult than RM, or on the radial arm maze, where RM was more difficult than WM. In the T-maze, MK-801 (0.1 mg/kg, IP, 30 min prior), CPP (30.0 mg/kg, IP, 2 h prior) and scopolamine (0.3 mg/kg, IP, 30 min prior) impaired both WM and RM, but the magnitude of the impairing effect was statistically greater for the WM component, the more difficult of the two components. Lower doses of these three compounds produced either selective effects on WM or no effect at all. In the radial arm maze all three drugs impaired both components, but the magnitude of the impairing effect was statistically greater for the RM component, the more difficult of the two components.(ABSTRACT TRUNCATED AT 250 WORDS)

Stages of change across ten health risk behaviors for older adults.

Owing to the recent success of the Transtheoretical Model of behavior change and the possible relationships between health behaviors, this study investigated the stage distribution of 10 healthy behaviors (seatbelt use, avoidance of high fat food, eating a high-fiber diet, attempting to lose weight, exercising regularly, avoiding sun exposure, sunscreen use, attempting to reduce stress, stopping smoking, and conducting cancer self-exams) and their interrelationships in a representative sample of health maintenance organization (HMO) members. The majority of older adults were found to be in either precontemplation or maintenance, illustrating the need to target interventions to precontemplation. Most older individuals were in precontemplation for losing weight and/ or sunscreen use and exercise, making these behaviors a priority for intervention research. Possible gateway behaviors to general health could be identified; however, these results are preliminary and require longitudinal follow-up.

Longitudinal changes in stages of change for condom use in women.

PURPOSE: This study identifies how women naturally progress through the Transtheoretical Model stages of condom use over a 1 year period, using the longitudinal dynamic methodology of latent transition analysis (LTA). DESIGN: As part of a larger study of human immunodeficiency virus risk in women, participants were assessed for their stage of condom use two times, 1 year apart. SUBJECTS: A total of 491 women who completed both assessments of the study were included in this analysis. MEASURES: Stage of condom use was assessed using two questions, which placed women into one of five stages of change for condom use (alpha = .90). RESULTS: Latent transition analysis identified the best-fitting model of naturalistic stage progression, which included both forward and backward movement. Precontemplation and maintenance were found to be the most stable stages (more than 50% of the participants remaining in that stage 1 year later), and the action stage was the least stable (15% remaining in this stage). Transition probabilities for all stages showed a high rate of relapse in the sample. CONCLUSIONS: A high proportion of women will remain within their stage of condom use over a 1-year period if no intervention is introduced. Interventions that are aimed at increasing condom use in women need to incorporate relapse prevention. In addition, the transition probabilities for the stages will help establish reasonable rates of change for intervention programs.

The College Alcohol Problems Scale.

A short, reliable two-factor instrument measuring drinking-related negative consequences was developed from a previous measure using two samples of college students. In Study I, data on alcohol use and problems associated with alcohol use were collected on 382 introductory psychology students. The original College Alcohol Problems Scale (CAPS) was tested and found to fit the data poorly. Sequential methods were used to develop a revised instrument. Principal components analyses (PCA) on half of the sample were conducted on 20 items written to measure negative consequences related to college student drinking. Results indicated a two-factor solution measuring social and emotional problems. Confirmatory factor analyses (CFA) on the other half of the sample confirmed the two-factor structure. Further refinement of the instrument resulted in the revised CAPS (CAPS-r), an eight-item two-factor scale. In Study II, the response format was altered to coincide with the Young Adult Problem Screening Test. A total of 726 students completed the instrument as part of a university-wide random sample. CFA showed that the hypothesized model fit well across all measures of model fit and the factor structure was invariant across gender. Additional analyses revealed that the scale was internally consistent and externally valid. A short reliable and valid measure of alcohol-related problems is needed to enable low-cost data collection on college campuses across the nation, as well as to facilitate program evaluation and routine epidemiological surveillance and monitoring.

Short form of a situational temptation scale for heavy, episodic drinking.

PURPOSE: A short form for situational temptations to drink scale was developed from an original 21-item inventory by Migneault. METHODS: The form measured four hypothesized subscales of temptations on a sample of 348 college drinkers (66% female). Peer pressure, social anxiety, negative affect, and positive/social situations subscales were replicated and reduced. RESULTS: Strong empirical support was found for a hierarchical model, indicating that the four subscales can be summed to provide a global measure of situational temptations. Confirmatory factor results, internal and external validity, and high correlations with the original measures indicate that the short form was as psychometrically valid as the original measure. IMPLICATIONS: Measures of external validity demonstrated the applicability of this measure to heavy drinking prevention programs.

Psychosocial factors influencing low fruit and vegetable consumption.

A major national health campaign has recently been initiated to promote consumption of 5 or more servings of fruits and vegetables each day. This paper investigates psychosocial factors related to fruit and vegetable consumption to understand better who might be receptive and who might resist the national 5-A-Day campaign. We studied 405 adult respondents to a random-digit dial telephone survey. Applying the Transtheoretical Model, respondents were classified by stage of readiness to adopt the practice of eating 5 or more fruits and vegetables each day. Logistic regression models were developed for persons consuming 2 or fewer servings daily and for persons in the Precontemplation stage. Education was directly related to fruit and vegetable intake and indirectly related to being in the Precontemplation stage. Males were twice as likely as females to be in the Precontemplation stage and eat fewer than 2 servings a day. Of special interest, respondents with children at home were at greater risk of eating 2 or fewer servings a day than those without children at home (OR = 1.63; 95% CI, 1.06-2.52). These results imply that stage of readiness to change should be considered as well as other factors in planning interventions for increasing fruit and vegetable consumption.

Public health and the science of behavior change.

PIP: This article explores the supposition that the efficacy and impact of public health interventions targeting behavioral and lifestyle factors can be improved by developing interventions that combine scientific advances in behavior change theory with advances in information technology. It is noted that programs of the public health revolution which began during the late 19th century have been based on biomedical theories to guide health promotion efforts for the purpose of increased public health impact. However, developments in behavior change research suggest that it is possible to incorporate behavior change theory into traditional large-scale public health intervention programs. It has been indicated that there is a need to align the field of health promotion and disease prevention with the science of behavior change for the development of theory-based intervention strategies for lifestyle change. The combination of advances in behavioral science and progress in information technologies provides a unique opportunity to enhance the efficacy, reach, and impact of the health promotion programs of the second public health revolution.^ieng

Stage distributions for five health behaviors in the United States and Australia.

BACKGROUND: A key variable for the design of individual and public health interventions is the Stage of Change. The five stages of readiness to change are Precontemplation, Contemplation, Preparation, Action, and Maintenance. The distribution of individuals across the stages of change can provide a valuable tool for designing health interventions. METHODS: The pattern of distribution across the stages of change for five behavioral risk factors is presented from five independent surveys, two from the United States and three from Australia. The five risk factors are smoking, low fat diet, regular exercise, reducing stress, and losing weight. Identical single-item questionnaire items for staging health behaviors were used in all surveys. RESULTS: The stage distributions for the five risk factors were similar across the five independent samples. In general, the pattern of stage distributions was stable across health risk factors, gender, country, and sample. CONCLUSIONS: Single-item survey measures of stage of change that are readily applicable to population studies appear to provide important information about the population characteristics of readiness to change behavioral risk factors. The stability of these distributions suggests that interventions matched by stage may have broad applicability.

Relationship marketing in health care.

Building relationships with patients is critical to the success of many health care organizations. The authors profile the relationship marketing program for a hospital's cardiac center and discuss the key strategic aspects that account for its success: a focus on a specific hospital service, an integrated marketing communication strategy, a specially designed database, and the continuous tracking of results.

Stage of regular exercise and health-related quality of life.

BACKGROUND: Research on cognitive factors and motivational readiness for exercise is important for increasing our understanding of behavior change among those with sedentary lifestyles. This study examines stage of change for regular exercise and self-perceived quality of life. METHODS: Data are from 1,387 respondents to a random digit dial survey of health behaviors. Stage of change is assessed with a single item, and individuals are classified with respect to intention and exercise behavior. Quality of life is assessed with the SF-36, a multidimensional measure of health-related quality of life. RESULTS: Exercise stage is associated with self-perceived quality of life. The three areas most strongly related were physical functioning, general health perceptions, and vitality. Physical functioning scores were lowest in precontemplation and highest in maintenance. Vitality and mental health scales were related to exercise behavior, but not to intention. CONCLUSIONS: Cognitions about self-perceived quality of life vary across the stages of change, with those who are least prepared to adopt regular exercise reporting the lowest levels of quality of life. These findings suggest that cognitive-motivational messages designed to emphasize quality of life benefits associated with exercise may be useful intervention strategies for people who are less motivationally ready to change.

Emergence and nosocomial transmission of ampicillin-resistant enterococci.

Between 1986 and 1988, the incidence of ampicillin-resistant enterococci increased sevenfold at a university-affiliated hospital. Forty-three patients acquired nosocomial infections with ampicillin-resistant enterococci, most of which were also resistant to mezlocillin, piperacillin, and imipenem. An analysis of plasmid and chromosomal DNAs of isolates revealed that the increase was due to an epidemic of 19 nosocomial infections that yielded closely related strains of Enterococcus faecium and to a significant increase in the incidence of nonepidemic, largely unrelated strains of ampicillin-resistant enterococci. The nonepidemic strains were identified as E. faecium, E. raffinosus, E. durans, and E. gallinarum. A logistic regression analysis revealed that patients with nonepidemic resistant strains were 16 times more likely than controls to have received preceding therapy with imipenem. In our institution, the increase in the incidence of ampicillin-resistant enterococci appears to be due to the selection of various strains of resistant enterococci by the use of imipenem and to the nosocomial transmission of E. faecium and E. raffinosus.

Counselor and stimulus control enhancements of a stage-matched expert system intervention for smokers in a managed care setting.

BACKGROUND: Previous research has demonstrated the efficacy of an interactive expert system intervention for smoking cessation for a general population. The intervention provides individualized feedback that guides participants through the stages of change for cessation. Enhancing the expert system by adding proactive telephone counseling or a stimulus control computer designed to produce nicotine fading could produce preventive programs with greater population impacts. METHODS: Four interventions were compared: (a) the interactive expert system intervention; (b) the expert system intervention plus counselor calls; (c) the expert system intervention plus the stimulus control computer; and (d) an assessment only condition. A 4 (intervention) x 4 (occasions) (0,6,12, and 18 months) design was used. Smokers were contacted at home via telephone or mail. The initial subject pool was the 24,178 members of a managed care company. Screening was completed for 19,236 members (79.6%), of whom 4,653 were smokers; 85.3% of the smokers were enrolled. RESULTS: Thirty-eight percent were in the precontemplation stage, 45% in the contemplation stage, and only 17% in the preparation stage. At 18 months, the expert system resulted in 23.2% point prevalence abstinence, which was 33% greater than that of assessment only. The counselor enhancement produced increased cessation at 12 months but not at 18 months. The stimulus control computer produced no improvement, resulting in 20% worse cessation rates than the assessment only condition. CONCLUSIONS: The enhanced conditions failed to outperform the expert system alone. The study also demonstrated the ability of the interactive expert system to produce significantly greater cessation in a population of smokers than assessment alone.

Measuring support for tobacco control policy in selected areas of six countries.

OBJECTIVE: To explore the validity, reliability, and applicability of using a short, psychometrically sound survey instrument to measure population attitudes toward tobacco control policies. DESIGN: Surveys. SUBJECTS AND SETTING: Student respondents attending university in Australia (n = 403), Hong Kong (n = 336), the Netherlands (n = 351), South Africa (n = 291), the United Kingdom (n = 164) and the United States (n = 241); total n = 1786. MAIN OUTCOME MEASURE: The Smoking Policy Inventory (SPI), a 35-item scale. SPI scores were adjusted for age, income, gender, and smoking status. Estimates of internal consistency and tests of factorial invariance were conducted in each sample. RESULTS: Across all six countries, the SPI was found to be highly reliable and to have a consistent factor structure, indicating that the SPI scale represents a higher order construct that assesses general attitudes about tobacco control policy with five dimensions. In general, the degree of endorsement of anti-tobacco policies as measured by the SPI reflected the extent and strength of tobacco control legislation in those countries. Dutch students were the least likely, and Australian and Hong Kong students the most likely, to support tobacco control policies. CONCLUSIONS: It is possible to develop appropriate and meaningful measurement tools for assessing support of tobacco control policies. Strong evidence was found for internal reliability and structural invariance of the SPI. The SPI may be a useful mechanism for monitoring ongoing policy initiatives, making cross-cultural comparisons, and evaluating population receptiveness to proposed policy approaches.